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Hand washing and hand disinfection:more than your mother taught youJonathan D.Katz,MDa,b,*aYale University School of Medicine,333 Cedar Street,New Haven,CT 06520,USAbDepartment of Anesthesiology,St.Vincent Medical Center,Bridgeport,CT 06606,USAAnd Aaron and his sons shall wash their hands...that they die not.Exodus 30The importance of thorough hand washing for protection against variousforms of communicable disease has been known since early recorded history.Itssignificance for the practice of medicine,however,was not generally appreciateduntil the pioneering works of Oliver Wendell Holmes (1843) [1] and Ignaz PhillipSemmelweiss (1846) [2],who independently recognized the role of contagionson the hands of doctors in the spread of puerperal fever,and Joseph Lister [3],who identified the importance of antisepsis in the practice of surgery.Thirty yearslater,largely through the work of William Halstead and others at Johns HopkinsUniversity,the use of rubber gloves during surgery became routine practice,andthe era of aseptic surgery was introduced.The scientific basis for the practices of hand hygiene (see Box 1) did notemerge until the introduction of the germ theory of disease by Louis Pasteur [4]and the delineation of the relationship between a specific microorganism(Bacillus anthracis) and its resultant disease (anthrax) by Robert Koch [5].SkinHuman skin is composed of four distinct layers,each performing a specificphysiologic function.The outermost layer,the stratumcorneum,is composed of atough horny layer of keratin bound together by a number of different skin lipids.This layer of skin serves as the primary permeable barrier against water loss fromthe body and penetration of water and other chemicals into the system.0889-8537/04/$ – see front matter D 2004 Elsevier Inc.All rights reserved.doi:10.1016/j.atc.2004.04.002* Department of Anesthesiology Yale University School of Medicine,333 Cedar Street,NewHaven,CT 06520.E-mail address:jonathan.katz@yale.eduAnesthesiology Clin N Am22 (2004) 457–471Box 1.Indications for hand washing and hand antisepsisa‘‘Hand washing’’ is defined as a process for removal of soil andtransient microorganisms fromthe hands.Hands should be washedwith soap and water or disinfected:1.When hands are visibly dirty or contaminated with protein-aceous material or are visibly soiled with blood or other bodyfluids,wash hands with either a non-antimicrobial soap andwater or an antimicrobial soap and water.2.If hands are not visibly soiled,use an alcohol-based handrub for routinely decontaminating hands in all other clinicalsituations described in items 3–10 below.Alternatively,wash hands with an antimicrobial soap and water in all clini-cal situations described in items 3–10 below.3.Decontaminate hands before having direct contact withpatients.4.Decontaminate hands before donning sterile gloves wheninserting a central intravascular catheter.5.Decontaminate hands before inserting indwelling urinarycatheters,peripheral vascular catheters,or other invasivedevices that do not require a surgical procedure.6.Decontaminate hands after contact with a patient’s intactskin (eg,when taking a pulse or blood pressure and liftinga patient).7.Decontaminate hands after contact with body fluids or ex-cretions,mucous membranes,non-intact skin,and wounddressings if hands are not visibly soiled.8.Decontaminate hands if moving from a contaminated bodysite to a clean body site during patient care.Decontaminatehands after contact with inanimate objects (includingmedical equipment) in the immediate vicinity of the patient.9.Decontaminate hands after removing gloves.10.Before eating and after using a restroom,wash hands with anon-antimicrobial soap and water or with an antimicrobialsoap and water.11.Antimicrobial-impregnated wipes (ie,towelettes) maybe considered as an alternative to washing hands withnon-antimicrobial soap and water.Because they are not aseffective as alcohol-based hand rubs or washing hands withan antimicrobial soap and water for reducing bacterialcounts on the hands of HCWs,they are not a substitutefor using an alcohol-based hand rub or antimicrobial soap.J.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471458Deep to the stratum corneum is the epidermis.The epidermis is a metabol-ically active,stratified squamous,cornifying epithelium that is populated bykeratinocytes (synthesis of keratin),melanocytes (skin pigmentation),Langer-hans cells (antigen identification and immune response),and Merkel cells (low-threshold touch receptors).Deep to the epidermis is the dermis.The dermis is composed largely ofnoncellular connective tissue in which is imbedded nerves,blood and lymphaticvessels,muscle tissue,and follicular,sebaceous,apocrine,and endocrine units.The hypodermis is the layer of subcutaneous fat that lies deep to the true skinelements described above.Human skin is normally colonized with a bacterial flora.The microbialcomposition and count of the skin flora vary depending on gender,age,healthcondition,and location on the body.Bacteria found on the hands reside in highestconcentrations in the subungual area and are divided into three categories:resident flora (permanently reside in the stratum corneum),transient flora (occuras skin contaminants),and infectious flora (the causal agents of hand infections).The resident flora on the hands are composed of a large number of microbialspecies,including the gram-positive Micrococcaceae (Staphylococcus epidermidis,S.hominis,and S.captitis),Corynebacterium (Corynebacterium jeikeium),andPropionibacterium (Propionibacterium acnes and P.granulosum).S.aureus isfrequently present,especially among health care workers (HCWs) [6].Gram-negative organisms such as Acinetobacter and members of the Klebsiellagenus of the Enterobacteriaceae family also frequently reside on the hands ofHCWs.The resident flora are relatively resistant to removal by hand washingand contribute to resistance against colonization by other,potentially patho-genic microorganisms.The transient flora occur as contaminants on the more superficial layers of theskin and are characterized by their inability to reproduce on the skin.Compared12.Wash hands with non-antimicrobial soap and water or withantimicrobial soap and water if exposure to Bacillus anthracisis suspected or proven.The physical action of washing andrinsing hands under such circumstances is recommendedbecause alcohols,chlorhexidine,iodophors,and other anti-septic agents have poor activity against spores.aData from Boyce JM,Pittet D.Guideline for hand hygiene inhealth-care settings.recommendations of the Healthcare InfectionControl Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.Society for HealthcareEpidemiology of America/Association for Professionals in InfectionControl/Infectious Diseases Society of America.MMWR 2002;51:1–45.J.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471 459with the resident flora,the transient flora colonize more readily with pathogenicorganisms,are most frequently associated with health care-associated infections,and are most susceptible to hand washing.The infectious flora are the causalagents of such hand infections as abscesses and paronychia.The commonestpathogenic organisms found on the hands are S.aureus and various streptococci.Protocols for hand disinfectionProtocols for the prevention of hand-associated microbial transfer include theuse of surgical gloves,the proper use of instruments to replace direct handcontact,and hand hygiene protocols.Hand hygiene practices include the standardhand wash (soap and water),the hygienic hand wash (medicated soap),thehygienic hand rub (fast-acting antiseptic solutions),and the surgical hand scrub.Recommendations for hand hygiene practices in hospitals have been issued bya number of professional organizations,including the American Society ofAnesthesiologists [7].Formal written protocols have been published by theCenters for Disease Control and Prevention (CDC) (1975 [8] and 1985 [9])and the Association for Professionals in Infection Control and Epidemiology(AIPC) (1988 [10] and 1995 [11]).Guidelines have also been published by theHealth care Infection Control Practices Advisory Committee (HICPAC) (1995[12] and 1996 [13]) and the Association of Operating Room Nurses (AORN)(1997 [14] and 1999 [15]).In 2002,the CDC consolidated and updated thesedocuments with its ‘‘Guidelines for Hand Hygiene in Health care Settings:Recommendations of the Health care Infection Control Practices AdvisoryCommittee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force’’(www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm) [16].These guidelinesare a comprehensive document that provides a thorough analysis of the science ofhand hygiene,with specific recommendations for the why’s and how’s of handhygiene practices in the modern health care settings (Boxes 1–3).One important innovation found in the new CDC guideline,with implicationsfor the practicing anesthesiologist,is the recommendation that alcohol-basedhand rubs be readily available and,in many cases,can be substituted for atraditional hand washing with soap and water.This is particularly useful in anoperating room where the anesthesiologist is unable to leave the patient’s bedsideto go to a scrub sink before or after a procedure,such as line placement.Hand hygiene productsSoapSoaps are detergent-based products that rely on their detergent properties toprovide cleansing functions.Unless antiseptics are added,plain soaps provideminimal antimicrobial activity.Frequent hand washing with plain soap can causedryness and irritation and,paradoxically,increases in bacterial counts [17].J.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471460AlcoholsAlcohol antiseptics contain isopropanol,n-propanol,or ethanol.Alcoholsproduce their antimicrobial action primarily by denaturing proteins.In concen-trations of 60% to 95% by weight,alcohol antiseptics provide excellentantibacterial,antifungal,and antiviral activities and rapid and persistent reduc-tions in microbial counts on skin [18].In many commercial preparations,additional chemicals,such as hydrogen peroxide or iodine,are added to enhanceantiviral or sporicidal activity.Alcohol-based hand rubs are now available asBox 2.Recommended hand hygiene techniquea‘‘Hand hygiene’’ is an inclusive termthat includes washing withsoap and water and/or performing antisepsis with a waterlessantiseptic agent.1.When decontaminating hands with an alcohol-based handrub,apply product to palm of one hand and rub hands to-gether,covering all surfaces of hands and fingers,until handsare dry.Follow the manufacturer’s recommendations regard-ing the volume of product to use.2.When washing hands with soap and water,wet hands firstwith water,apply an amount of product recommended by themanufacturer to hands and rub hands together vigorously forat least 15 seconds,covering all surfaces of the hands andfingers.Rinse hands with water and dry thoroughly with adisposable towel.Use towel to turn off the faucet.Avoidusing hot water,because repeated exposure to hot watermay increase the risk of dermatitis.3.Liquid,bar,leaflet,or powdered forms of plain soapare acceptable when washing hands with a non-antimicrobialsoap and water.When bar soap is used,soap racks thatfacilitate drainage and small bars of soap should be used.4.Multiple-use cloth towels of the hanging or roll type are notrecommended for use in health-care settings.aData from Boyce JM,Pittet D.Guideline for hand hygiene inhealth-care settings.recommendations of the Healthcare InfectionControl Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.Society for HealthcareEpidemiology of America/Association for Professionals in InfectionControl/Infectious Diseases Society of America.MMWR 2002;51:1–45.J.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471 461rinses,gels,and foams.The major disadvantage of alcohol-based antisepsis is thedrying effect on the skin.Commercially prepared products frequently includeemollients,humectants,and other skin-conditioning agents to minimize thedrying effect of the alcohol.ChlorhexidineChlorhexidine gluconate produces its antimicrobial activity by increasing thepermeability of the microbial cell,disrupting cytoplasmic membranes,andprecipitating cell contents.A major disadvantage of chlorhexidine gluconate isits slow onset and relatively narrow range of antimicrobial activity.Its majoradvantage is its superior residual activity.It is most commonly used in com-Box 3.Surgical hand antisepsisa1.Remove rings,watches,and bracelets before beginning the‘‘surgical hand scrub’’ (ie,a process to remove or destroytransient microorganisms and reduce resident flora.2.Remove debris from underneath fingernails using a nailcleaner under running water.3.‘‘Surgical hand antisepsis’’ (ie,a process for removal or de-struction of transient microorganisms) using either an anti-microbial soap or an alcohol-based hand rub with persistentactivity is recommended before donning sterile gloves whenperforming surgical procedures.4.When performing surgical hand antisepsis using an antimi-crobial soap,scrub hands and forearms for the length of timerecommended by the manufacturer,usually 2–6 minutes.Long scrub times (eg,10 minutes) are not necessary.5.When using an alcohol-based surgical hand-scrub productwith persistent activity,follow the manufacturer’s instruc-tions.Before applying the alcohol solution,prewash handsand forearms with a non-antimicrobial soap and dry handsand forearms completely.After application of the alcohol-based product as recommended,allowhands and forearms todry thoroughly before donning sterile gloves.aData from Boyce JM,Pittet D.Guideline for hand hygiene inhealth-care settings.recommendations of the Healthcare InfectionControl Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.Society for HealthcareEpidemiology of America/Association for Professionals in InfectionControl/Infectious Diseases Society of America.MMWR 2002;51:1–45.J.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471462bination with other hand hygiene products.Chlorhexidine gluconate is associatedwith a relatively low incidence of skin irritation but has been reported to causeisolated cases of contact dermatitis and anaphylactic allergic reactions [19].ChloroxylenolChloroxylenol,also known as parachlorometaxylenol,derives its antimicro-bial action by deactivating bacterial enzymes.Most commonly used as anantimicrobial agent in soaps,parachlorometaxylenol does not consistentlydemonstrate a broad spectrum of antimicrobial effectiveness or residual activityas compared with many of the other commercially available antiseptics.HexachloropheneThe antimicrobial activity of hexachlorophene is its ability to inactivateenzyme systems and to disrupt microbial cell walls.Once universally endorsedfor hygienic hand washing,it has become less popular in recent years because ofits relatively narrow range of antimicrobial action [20] and the demonstrationof harmful systemic absorption after extended use [21].The major advantageof hexachlorophene is its persistent activity [20].IodophorsIodophors are complexes composed of iodine and a carrier such as poly-vinylpyrrolidone (or povidone).The iodine exerts its antimicrobial action bycrossing cell walls and substituting microbial contents with free iodine.Iodophorshave a relatively wide range of antimicrobial activity.Problems associated withiodophor use are a relatively high incidence of skin irritation and allergicreactions,and the partial neutralization of activity in the presence of organicmaterials such as blood or sputum [22].Quaternary ammonium compoundsMembers of this large group of complex compounds have been among theearliest antiseptics used routinely for surgical hand scrubs.They act by adsorptiononto the cytoplasmic membrane,with subsequent leakage of cytoplasmic con-tents.These compounds are primarily bacteriostatic and fungistatic and are moreactive against gram-positive than gram-negative bacteria.TriclosanTriclosan is a diphenyl ether.Its antimicrobial activity results from the entryinto the bacterial cell where it impedes the synthesis of RNA and proteins.Incommon clinical usage,triclosan is more bacteriostatic than bacteriocidal and haslimited efficacy against Pseudomonas aeruginosa and most fungi.It is minimallyJ.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471 463affected by the presence of organic matter or blood and has the advantage ofexcellent persistent activity.Surgical scrubThe surgical hand scrub is a specialized form of hand hygiene,with its owntraditions and rituals.First introduced by Semmelweiss,who used chlorinatedlime [2],surgical hand scrubbing became a standard practice because of the workof Lister [3],who used carbolic acid to soak his fingers and surgical instruments.The intended goal of the surgical hand scrub is to reduce surgical infections byremoving dirt and debris and reducing the resident flora from the hands of thesurgical team for the duration of a procedure.An effective surgical scrub shouldideally provide the following antimicrobial effects:1.Immediate reduction in the resident bacterial flora that is associated withsurgical site infections2.Sustained effect to maintain a reduced bacterial count under surgical gloves3.Cumulative effect,so that each additional application of the antisepticfurther reduces the microbial count4.Persistent effect that results in a progressive reduction of the skin flora withrepetitive use of the agentUnfortunately,the precise role of the surgical hand scrub in the incidence ofsurgical wound infections is unclear [23].The traditional 10-minute surgicalscrub,using a stiff brush and harsh chemicals,does not meet the criteria forsatisfactory antimicrobial action (an immediate reduction in microbial count thatis sustained,cumulative,and persistent) and is associated with a number ofdifficulties and problems,chiefly a high incidence of irritation and dermatitis thatcan paradoxically result in an increased microbial population on the hands of thesurgical team [17].Frequent surgical scrubs also expose HCWs to potential health risks.As manyas 85% of HCWs [24],and anesthesiologists [25,26] specifically,have a historyof irritant and allergic contact dermatitis attributed to the detergents in handhygiene products.Frequent scrubbing also results in a reduction in the benignresident flora and an increased vulnerability to contaminating pathogenic micro-organisms such as Klebsiella spp and Escherichia coli [6,17,27].A number of modifications have been made to the traditional surgical handscrub to enhance its salutary effects and minimize its harmful effects.Theduration of recommended scrub time has been decreased so that a 2-minutescrub time is now considered by many to be optimal [23].Many authors haverecommended the complete elimination of the use of a scrub brush,to minimizeabrasion of the hands [28,29].Several new antiseptics,as well as emollients andhumectants,have been introduced to minimize the dryness and dermatitisresulting from the surgical hand scrub.Some HCWs have begun to routinelyJ.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471464apply barrier creams in an attempt to further minimize irritant contact dermatitis,but their effectiveness has been questioned [30],and a potentially harmful role insolubilizing proteins in rubber gloves has been identified [31].Compliance with hand hygiene standardsUnfortunately,HCWs are generally complacent about following even basichand hygiene practices.As few as 5%[32] and on average 48%[33] of all HCWscomply with the fundamentals of hand hygiene practices.HCWs,on average,wash or disinfect their hands in half the reported instances [33].Physicians haveconsistently been shown to be the least compliant of all HCWs studied [33,34].Hand hygiene practices are particularly lax in intensive care areas of hos-pitals,including the operating room suites (outside of the surgical field) andbefore high-risk procedures are performed [35,36].There have been few reports[37] of hand hygiene practices and infection control specifically among anes-thesiologists,but there is apparently no better compliance among anesthesiolo-gists than other intensive care clinicians.For example,a 1995 study [38] ofAmerican anesthesiologists reveals that only 58% always washed their handsafter contact with patients considered ‘‘low risk’’ for infection with HIVor HBV.In a 1999 report on British anesthesiologists,gloves were always used duringanesthetics by 14.5% of the respondents,and only 36.4% washed their handsbetween cases [39].In a survey of Australian anesthesiologists,1% of respon-dents felt that epidural catheters could safely be placed without wearing sterilegloves [40].Similarly,hand hygiene practices in post-anesthesia care units (PACUs) are nobetter in other intensive care settings.Indeed,risk factors associated with thehighest rate of noncompliance in intensive care units,such as a heavy workload,alarge number of independent contacts between patient and HCW,a high intensityof patient care,an elderly patient population,and the concurrence of a number ofpatient-care demands,are all experienced as well within operating rooms andPACUs [41].The open ward architecture of most PACUs also makes it less likelythat staff will rigidly adhere to optimal hand hygiene practices.A recent study byPittet et al [42] examined hand washing practices in a PACU.They observed thatthe staff’s average compliance with hand hygiene protocols when admitting anew patient to the PACU was 19.6%.Compliance for patients already admitted tothe PACU was 12.5%.It is not surprising that there is better compliance when the HCWperceives asignificant threat to his/herself [43].For example,when caring for a PACU pa-tient who has undergone a ‘‘dirty’’ surgical procedure,approximately 95% ofthe staff washed their hands after contact with a patient thought to be carryingHIVor HBV,compared with only 58% who washed after treating these patientsand considered themselves to be free of these viruses [38].In addition to washing their hands less frequently than is recommended,HCWs frequently do not wash thoroughly (including all surfaces of the hands andJ.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471 465fingers) or for an adequate duration [23].Most protocols recommend a minimumof 30 seconds of hand washing;however,the average time spent in washing byHCWs is less than 10 seconds [44].A number of factors contribute to this overall dismal rate of compliance withrecommended hand hygiene practices.A major contributing factor is a lack ofawareness among HCWs of the patient-care activities that require hand washing(see Box 1).For example,it is not generally appreciated that HCWs cancontaminate their hands with pathogenic organisms even while performing‘‘clean’’ activities such as taking a patient’s blood pressure or even touching apatient’s hand [45].Less well appreciated is how readily communicable diseasescan be transmitted simply by contact with inanimate objects in the proximity ofinfected patients [46].Also,among HCWs there is a common misconception thatwearing gloves and gown serves as a substitute for hand washing [47].Other important factors contributing to poor hand hygiene practices includethe unpredictable and sporadic nature of the workload distribution and variouslogistical barriers (such as the location of scrub sinks) [48,49].Overcrowding ofpatients and understaffing of personnel with a corresponding high workload haveboth been consistently associated with poor compliance with hand hygienepractices [36,50–52].Skin irritation and dryness resulting from frequent handwashing is also commonly cited as a reason for inadequate or infrequent handwashing [49].Attempts are being made to provide solutions to the problems of inadequatehand hygiene practices.An important first step is the increased availability ofantiseptic solutions that cause minimal drying and contain protectants tominimize irritation to the skin of the hand [49].These products must be readilyaccessible to HCWs at the patient’s bedside [53].By replacing the traditionalsink-based hand wash with a bedside antiseptic hand rub,HCWs can reduce thetime necessary to wash between patient encounters by 75% [54],suffer less skinirritation,experience better antisepsis,and consequently be more inclined toadhere to their hospital’s hand hygiene protocol.Hospitals are also increasingtheir efforts to monitor compliance and to provide feedback to HCWs on theirperformance of this procedure [55].Consequences of poor hand hygieneNosocomial infectionsIt has been estimated that 1 of every 20 hospitalized patients contracts anosocomial infection,resulting in 80,000 deaths annually in the United States[56].The majority of these infections are caused by the transmission of micro-organisms on the hands of health care providers who have either not washed theirhands or did so inadequately between patients [11,57,58].Hand washing is thesingle most important preventative measure to avoid health care provider-to-patient transmission of disease [11].J.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471466Clear evidence exists for the consequences of inadequate hand hygiene.Thosefactors associated with poor adherence with hand hygiene protocols,such asunderstaffing,patient overcrowding,and high workload (see above) are alsoassociated with outbreaks of communicable diseases in hospitals [41].In fact,most nosocomial infections in intensive care units and PACUs are the result ofcross-contamination frommicroorganisms carried on the hands of HCWs [58,59].A study reported in 1962 by Mortimer et al [60] demonstrated that 92%of infantswho were cared for by nurses who did not wash their hands between patientsacquired S.aureus from an index infant.Only 53%of infants who were cared forby nurses who did wash their hands acquired the infection.Similarly,inadequatehand washing among hospital staff has been identified as the primary cause ofclusters of infection from Klebsiella spp [45],P.aeruginosa [61],and Entero-bacter cloaca [41].Conversely,improvements in hand hygiene practices have a clearly demon-strable positive impact on nosocomial infection rates [62,63].This was firstdemonstrated when Semmelweiss showed a reduced rate of mortality amongmothers after staff had been instructed to wash their hands with an antisepticagent between patients [2].In many cases,the spread of hospital-acquiredinfections can be limited by the simple act of improving hand washing practicesamong staff [63,64].For example,infection by hospital-acquired Klebsiella spp.has been contained by requiring more frequent hand washing among hospitalstaff [46].Other health care-associated pathogens,including methicillin-resistantS.aureus have been contained by changing the antiseptic agent used for handwashing [61,65,66].Risks to HCWLack of compliance with recommended hand hygiene protocols also places thehealth care worker in jeopardy of acquiring their patient’s communicable dis-eases.A broad spectrum of infectious diseases has been transmitted from patientto health care provider as a result of contact exposure.Infections and organismsthat carry a particularly high risk of transmission include chickenpox,conjunc-tivitis,influenza,measles,mumps,human paravirus B19,pertussis,respiratorysyncytial virus,rotavirus,rubella,S.aureus,Streptococcus,and tuberculosis.Conjunctivitis is a good example of a disease that is relatively uncommon inthe general adult population but is frequently seen among HCWs and is avoidablewith proper attention to hand hygiene.Most health care-associated epidemics ofconjunctivitis are caused by an adenovirus that is contracted after contact with aninanimate reservoir (such as a linen roll towel dispenser) or a person harboring thevirus.The most efficient way to interrupt transmission of conjunctivitis is to iden-tify and isolate the source and to impose strict hand washing standards [67,68].In addition to facilitating the direct transmission of disease,inadequate handhygiene can promote a transition to a more pathogenic residual flora amongHCWs.For example,before the routine use of gloves for most patient contactactivities,as many as 30% of nurses were shown to harbor significant counts ofJ.D.Katz/Anesthesiology Clin N Am 22 (2004) 457–471 467S.aureus and gram-negative bacilli on their hands [18].S.aureus was cultured in78%of nurses who worked exclusively with dermatology patients.More recently,well into the era of Universal Precautions,pathogenic organisms were culturedfrom the hands of 19% of hospital staff [55].SummaryHand washing is considered the single most important intervention forprevention of nosocomial infections in patients and health care workers.Unfor-tunately,compliance with standard protocols for hand hygiene in the health careenvironment has been generally poor.This is especially true in intensive careareas such as operating rooms and post-anesthesia care units.Procedures and products used for hand washing have undergone significantimprovements in the most recent decade.Most of these changes were imple-mented specifically with the goal of improving compliance with hand hygienepractices.Recent modifications have been consolidated into the publication‘‘Guideline for Hand Hygiene in Health care Setting’’ that was issued by theCDC in 2002 [16].In this article we have discussed the rationale and practicalapplication of current protocols for hand hygiene as they specifically apply to thepractice of anesthesiology.References[1] Holmes OW.The contagiousness of puerperal fever.New England Quarterly Journal of Medi-cine and Surgery 1842;3:503–30.[2] Semmelweis I.The etiology,concept,and prophylaxis of childbed fever.Translated by K.CodellCarter.Madison,Wisconsin:The University of Wisconsin 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